What I don’t like is when an 85-year-old with an altered level of consciousness is directed to our outpatient center in the name of cost containment. Unfortunately, this sort of thing has been happening a lot lately, and it has me worried. So while I agree with the goals of the law, I do have some concerns about how it's being applied.
I realize what we're all up against. It would be nice if someone in the government would provide a nice evidence-based blueprint for PHM (or bundled payments or ACOs, for that matter), but that’s not how it works. The truth is, many mandated reforms will be developed and tested as we go.
The sooner we hone in on workable solutions, the sooner we’ll start realizing the goals of expanded access and improved quality. And in order for PHM get off on the right foot, I believe there are two potential problem areas we need to address.
Keeping the ED in the Acute Care ContinuumIt’s true that many EDs are crowded. It’s also true that they’re costly for both patients and the system. And undoubtedly some patients who present to the ED would do just as well with a lower level of care. (Though if you drill down into the research, the number of truly "preventable" ED visits is surprisingly small.)
Despite this, our industry needs to rethink the negative messages it's sending about ED utilization. Managed care companies are working hard to convince patients and providers that the ED is a destination of last resort, a place to be avoided unless one is having a stroke or heart attack. Urgent care centers reinforce this message by explicitly marketing themselves as cheaper alternatives to the ED.
This creates a few problems. First, going to urgent care when the ED would be more appropriate wastes time, which can be dangerous. In too many cases, delaying emergency care only leads to worse outcomes and higher costs down the road. In a recent ACEP survey, 77 percent of emergency physicians said they’re seeing patients with more complicated issues due to the growth of urgent care centers.
The benefits of the ED aren’t just medical. An ED visit can be a springboard to needed post-acute care. Unlike most urgent care centers, EDs generally have social workers and case managers who help to ensure appropriate follow-up. And more and more EDs are developing transition planning programs that enhance care continuity and connect patients with needed resources. This sort of support can make a big difference in patient outcomes.
Bottom line: Sometimes doing just a little bit more in the ED can save costs and time and lead to better outcomes downstream.
Management Requires AccessAnother potential pitfall of PHM is its focus on the seriously ill. Pioneering providers and demonstration programs seem to be pouring most of their efforts into the sickest 1 to 3 percent of patients — those with complex illnesses and multiple chronic conditions.
Admittedly, PHM has to start somewhere, and the very ill represent the low-hanging fruit. To put things in perspective, the sickest 1 percent of patients account for nearly a quarter of healthcare spending. In my experience, PHM programs have been quite successful with this group. Interventions like care management and transition planning can do real good when it comes to improving outcomes and containing costs.
Where we haven’t done a job is in ensuring that the other 97 to 99 percent of patients access appropriate care. Granted, not all of these patients need care right now. But there’s a sizable population with health risk factors and emergent chronic conditions. And in many cases, they’re having difficulty accessing preventative care that could prevent them from getting much sicker down the road.
Here’s an example we see a lot here in Southern California. A lower-income family, the Smiths, is covered by Insurance Company X through Mrs. Smith’s employer. When the health exchanges launched last year, the employer opted to discontinue its health insurance program. Instead, they gave Mrs. Smith money to shop for an exchange plan.
She visits the Covered California website and buys a new plan, also through Company X. She assumes it’s the same coverage her family had before. What she doesn’t know is that when Company X set up its exchange plans, it opted to reimburse that care at much lower rates — in some cases, significantly less than Medicare.
Company X defends its tiered reimbursement system, saying the participating physicians will make up the difference in higher patient volume. To practicing physicians, this is a joke. Pretty much every primary care provider in the area is already operating above capacity. As much as they may support the goals of healthcare reform, they can’t survive on the exchange rates. As a result, very few southern California physicians have opted to participate in the health exchanges.
As a result, the Smiths call every doctor in Company X’s network, but can’t find any who will take them as patients. In fact, many of the doctors aren’t participating in the exchanges at all. The Smiths’ only remaining option is to pay cash for their care or to get it in the ED.
So what can be done? As much as I’m reluctant to call for a government solution, I don’t think things will get better for exchange patients unless the federal government steps in to regulate the insurance industries. In order for healthcare reform to fulfill its promise, there need to be standards for physician reimbursement. Insurance companies must also be held accountable for maintaining sufficiently robust networks capable of providing appropriate care for the patients they sign up.
And to bring this all back around to PHM, those of us participating in its development and testing need to consider the benefits of casting a wider net. We’ve seen some pretty positive results among the 1 percent. But to truly contain costs in the long run, we need to expand our efforts to those who may be at-risk, yet struggling to navigate a system in flux.